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$93,000 cancer drug

a first-of-a-kind therapy approved in April. It costs $93,000 and adds four months' survival, on average, for men with incurable prostate tumors.

For the last decade, new cancer-fighting drugs have been topping $5,000 a month. Only a few of these keep cancer in remission so long that they are, in effect, cures. For most people, the drugs may buy a few months or years. Insurers usually pay if Medicare pays. But some people have lifetime caps and more people are uninsured because of job layoffs in the recession. The nation's new health care law eliminates these lifetime limits for plans that were issued or renewed on Sept. 23 or later.

Celgene Corp.'s Revlimid pill for multiple myeloma, a type of blood cancer, can run as much as $10,000 a month; so can Genentech's Avastin for certain cancers. Now Dendreon Corp.'s Provenge rockets price into a new orbit.

Unlike drugs that people can try for a month or two and keep using only if they keep responding, Provenge is an all-or-nothing $93,000 gamble. It's a one-time treatment to train the immune system to fight prostate tumors, the first so-called "cancer vaccine." Part of why it costs so much is that it's not a pill cranked out in a lab, but a treatment that is individually prepared, using each patient's cells and a protein found on most prostate cancer cells. It is expensive and time-consuming to make.

It's also in short supply, forcing the first rationing of a cancer drug since Taxol and Taxoterewere approved 15 years ago. At the University of Texas M.D. Anderson Cancer Center, doctors plan a modified lottery to decide which of its 150 or so eligible patients will be among the two a month it can treat with Provenge. An insurance pre-check is part of the process to ensure they financially qualify for treatment.

"I'm fearful that this will become a drug for people with more resources and less available for people with less resources," said M.D. Anderson's prostate cancer research chief, Dr. Christopher Logothetis.

For other patients on other drugs, money already is affecting care:

_Job losses have led some people to stop taking Gleevec, a $4,500-a-month drug by Novartis AG that keeps certain leukemias and stomach cancers in remission. Three such cases were recently described in the New England Journal of Medicine, and all those patients suffered relapses.

_Retirements are being delayed to preserve insurance coverage of cancer drugs. Holly Reid, 58, an accountant in Novato, Calif., hoped to retire early until she tried cutting back on Gleevec and her cancer recurred. "I'm convinced now I have to take this drug for the rest of my life" and will have to work until eligible for Medicare, she said.

_Lifetime caps on insurance benefits are hitting many patients, and laws are being pushed in dozens of states to get wider coverage of cancer drugs. In Quincy, Mass., 30-year-old grad student Thea Showstack testified for one such law after pharmacists said her first cancer prescription exceeded her student insurance limit. "They said 'OK, that will be $1,900,'" she said. "I was absolutely panicked." The federal health care law forbids such caps on plans issued or renewed Sept. 23 or later.

_Tens of thousands of people are seeking help from drug companies and charities that provide free medicines or cover copays for low-income patients. Genentech's aid to patients has risen in each of the last three years and the company says nearly 85 percent of Americans earn less than $100,000, making them potentially eligible for help if no other programs like Medicaid will pay.

_Doctors and insurers increasingly are doing the cruel math that many cancer patients want to avoid, and questioning how much small improvements in survival are worth. A recent editorial in a medical journal asked whether the extra 11 weeks that Genentech's Herceptin buys for stomach cancer patients justified the $21,500 cost.

Doctors also have questioned the value of Genentech's Tarceva for pancreatic cancer. The $4,000-a-month drug won approval by boosting median survival by a mere 12 days. Here's how to think about this cost: People who added Tarceva to standard chemotherapy lived nearly 6 1/2 months, versus 6 months for those on chemo alone. So the Tarceva folks spent more than $24,000 to get those extra 12 days.